Care Plan

Topics: Nursing care plan, Nursing, Health care provider Pages: 10 (2414 words) Published: February 22, 2013
Data Base and Nursing Care Plan

Student Name:Date:
Pathophysiology (Include Normal Physiology, identify the Physiological Alteration, identify sings and symptoms). M.P. is a 56 year old African American male, with a history of progressive multiple sclerosis with multiple contractures, chronic decubitus ulcers, chronic indwelling urinary catheter and known osteomyelitis (infection of the bone). Mr. P. was admitted on October 25th with sepsis, a systemic response to infection. He presented with a fever (102.7 F), confusion, tachycardia, and tachypnea and elevated WBC. Multiple sclerosis is a chronic disease of the central nervous system in which the myelin sheath are destroyed in regions of the brain and spinal cord. This results in temporary repetitive disruptions in never impulses conduction which causes symptoms of muscular weakness, loss of coordination, numbness, visual disturbances, and loss of bowel and bladder function. Mr. P has secondary progression of the disease which may result in a gradual accumulation of visual, motor or sensory disabilities. The cause of this disease is unknown (Tabers, 2005). Patient is full care related to his diagnosis of multiple sclerosis because of being unable to straighten legs. He currently lives at the VA in the Community Living Center. Patient must be kept on a strict turn schedule because of his multiple pressure ulcers. Patient also have PEG (percutaneous endoscopic gastrostomy), feeding tube that nutrition that is supplemental to soft food diet as tolerated. While we were there, patient only ate applesauce and ice cream.

Past Medical & Surgical History (if any) and effect on Admitting Diagnosis: Multiple sclerosis diagnosed in 1979, tobacco use 3-4 packs per day, osteomyelitis, and contracture of joint at multiple sites. Multiple sclerosis has definitely lead to depilating state, being unable to get out of bed has led to breakdown of skin causing multiple pressure wounds. Infection of bone (osteomyelitis) is a complication for wound healing because client has been on multiple antibiotic therapies that can cause resistance, which would open him up to further infection. Tobacco smoking also can cause a delay in wound healing.

Diagnostic Tests Lab/Radiology/EKG/Other Procedures

TestNormal RangeResultAbnormal?Significance for THIS Patient/Primary Function in Maintaining Homeostasis/Where does this element reside in the cell? Na+136-145 mEq/L134NVital for skeletal muscle contraction, cardiac contraction, nerve impulse transmission, and normal osmolality and volume of the ECF. K+3.5-5.0 mEq/L5.0NCritical for excitable tissues to depolarize and generate action potential. CL98-106 mEq/L102NFormation of hydrochloric acid in the stomach. HCO324-28 mEq/L22YVital component of the pH buffering system that maintains acid-base homeostasis. He has possible kidney impairment r/t numbness, and possible incontinence and the respiratory system may try to compensate for acid-base imbalance. BUN7-21 mg/dL27YWaste product derived from protein breakdown in the liver and a measurement of renal function. The kidney function is decreased r/t immobility, MS, and infection. Cr0.7-1.3 mg/dL0.8NSupplies energy to all cells in the body, primarily muscles. Increases formation of ATP. Glucose70-130 mg/dL116NSource of energy

Ca+9.0-10.5 mg/dL9.5
NMaintains bone strength and density, activating enzymes, allowing skeletal and cardiac muscle contractions, controlling nerve impulse transmission and blood clotting. Mg+1.3-2.1 mg/dLNCritical for skeletal muscle contraction, carbohydrate metabolism, ATP formation, vitamin activation and cell growth. PO+3.0-4.5 mg/dLNNeeded for activation of vitamins and enzymes, forming ATP, and assisting in cell growth and metabolism, as well as, acid-base balance and calcium homeostasis. CBCN

Hgb14-18 g/dL9.5YCarries oxygen and gives blood its red color. Hct42%-52%...

References: Ignatavicius, D., Workman, L (2010). Medical Surgical Nursing: Critical thinking for collaborative care (6th Ed.). St Louis: Elsevier
Micromedex. Truven Health Analytics. (2012). Micromedex Drug Information. Mobile application for iphone. Last retrieved on
October 6, 2012.
Swearingen, Pamela, L. (2008). All-in-one care planning resource (2nd ed.). St. Louis, MO: Mosby Elsevier.
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